Provider Demographics
NPI:1295345973
Name:ATTA, AGBONLUAI EMMANUEL
Entity type:Individual
Prefix:DR
First Name:AGBONLUAI
Middle Name:EMMANUEL
Last Name:ATTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 GRAIDEN ST
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-1817
Mailing Address - Country:US
Mailing Address - Phone:301-404-7446
Mailing Address - Fax:
Practice Address - Street 1:211 GRAIDEN ST
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-1817
Practice Address - Country:US
Practice Address - Phone:301-404-7446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD25688183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist